The Importance of Social Care and Nursing Services

Transcription

1 State of the art of policies addressing aging in the concerned member states and regions of CREATOR (national-level, regional and local level policies) Elderly care synthesis I. Hungary Home help services in Hungary were organised in the late 1960's, primarily to care for the elderly, patients with chronic conditions and the homebound. Health care system has recently become decentralised and is mainly funded through social insurance contributions. The government has introduced a 1% nursing care insurance. Under the Local Government Act of 1990 and Act III of 1994 on Social Services, municipalities acquired responsibility for the elderly and disabled people, as well for social care. The Act on Social Welfare of 1993 made it possible, in certain cases, for family carers to receive a fee for providing care. Since 1993, each municipality has been required to meet local needs for home care, with contributions from the central budget based on the municipality's population size and number of inactive and unemployed persons. The services are provided by professional caregivers and volunteers, as well as specialist nurses who provide home nursing services under a doctor's orders. Efforts are being made to establish a separate home care and nursing service and to expand the insurance-based system of delivery to the non-profit agencies. Social care is funded through the welfare sector and not the health sector. The State relies heavily on cooperation with foundations, associations and church organisations. The practice of paying gratitude money persists in Hungary. Many elderly people feel that it is necessary in order to receive proper treatment. Some doctors even demand advance payments of gratitude money. Under Hungarian law, an elderly person can sign a maintenance contract with a person of their choice whereby the appointed carer inherits the old person s flat or house in exchange for caring for the elderly person. In the past, this led to cases of abuse but modern contracts with more safeguards now exist. Some people sign maintenance contracts with trusted neighbours. Social care includes home care nursing for medical problems and home care social support e.g. the provision of medication and meals, house cleaning and assistance in maintaining personal hygiene. Help with laundry and shopping is also included but much of this is also carried out by voluntary associations.

2 Transport to the doctor is also the responsibility of local authorities but this service does not extend to transport to other places such as to church, social gatherings or even to the hospital for medical examinations. Fortunately, some NGOs provide such services. Home nursing care is provided if prescribed by a doctor. In practice, many trained home help workers also provide home nursing care. The vast majority of home help workers are in fact trained nurses but the strict division between health and social care forbids this so both the elderly and the care workers sometimes falsify the records. The Maltese charity organisation provides integrated home care covering both home help and home care. Clubs for the elderly exist where people who are still partly able to care for themselves can go during the day. In these clubs, elderly people can profit from 1 to 3 meals per day, have a bath and take part in activities.

3 II. Italy In 1978, the National Health System was set up in Italy. In the same year, Local Health Authorities (USL) were created which were controlled by the municipalities. However, it was not until 2000 that a legal framework and financial basis for a national development of social services was established. Meanwhile, care for the elderly was entrusted to general practitioners, community care services organised by municipalities and associations. There is still a strong emphasis on support from the family. Care of the elderly is traditionally considered as a kind of social duty by the family, especially the women on whom the main burden of care falls. Demand for home care services has nevertheless increased significantly but supply has been fairly limited. The percentage of over 65 year-olds using home care services in Italy is very low. Moreover, there have been considerable differences in the development and distribution of home care services, particularly between the north and south of the country. There are also differences between the populations. For example in the north, elderly people tend to live in better conditions; on the islands, such as Sicily and Sardinia, there is a higher percentage of chronic diseases and disability. Services tend to be fragmented and public expenditure on health services is fairly low. Reform of the National Health System began in 1992 with the Health Care Decree no. 502/1992, followed by the Objective: Ageing Persons project (the National Plan for Welfare), Law no. 328/2000 relating to the creation of an integrated care and social services system and finally the Guidance and Coordination related to Health and Social Integration Act of The objective of the National Plan for Elderly People was to better coordinate medical and social services so as to ensure their integration within the home care services system. Related services are intended to promote the well-being of elderly people and to help them to maintain their autonomy. Every person in Italy, with insufficient financial resources, irrespective of age, can ask for alimony from his/her family. According to articles 433, 438 and 443 of the Civil Code, relatives can fulfil this obligation either by paying money every month or by accepting and supporting the person in their own home. In Italy, citizens must purchase a ticket in order to have access to services within the National Health Service. People who are over 65 years old and those suffering from an officially recognised chronic and disabling disease do not have to pay. The regions have legislative powers over health and welfare but home care services are financed entirely by Local Councils. Such services are generally rendered to people on low incomes. Elderly people may have to contribute towards costs using their pensions, vouchers and care payments. Those with extremely limited financial resources may be exempt from making these partial payments. A care system was set up in the framework of the National Plan for Elderly people which includes: Home Care (community care): with social importance (home help, meals and personal care); with health importance (medical, rehabilitative and/or nursing care); integrated.

4 Integrated Home Care Services: is a combination of integrated and coordinated health and social activities which seek to keep an elderly person at home as longer as possible. Health services are medical care (Geriatric, Psychiatry), nursing, rehabilitation, medicines and prosthesis supply. Social services are: personal care, meals, house work, laundry, administrative services. Day Centres: semi-residential structure, within the District, which hosts disabled elderly people for a shortterm period (they are open during the day, 5 days a week, 7 hours a day, and admit 20 elderly persons). They provide healthcare services (prevention, therapy, and rehabilitation), and social care services (personal care and promotion of personal autonomy, entertainment, job therapy, and social activities). Nursing homes: residential structure organised into small groups ( nuclei ), which provides healthcare, social care, and functional rehabilitation for people with disabilities. Patient care can be extensive or intensive. The first area comprises temporary accommodation for long-term care and rehabilitation (while hospitalisation is limited only to the acute stage). The second area comprises intensive rehabilitation, with high medical importance, plus a hospice for terminal patients which provides palliative care (reduction of pain; social protection for patients and their family; family support). Doctors, nurses, social workers and psychologists are available at the Nursing Home.

5 III. Poland During the Communist era, there was a comprehensive programme of health care benefits organised and provided by the State. In 1999, the Health Insurance Act introduced an obligatory health insurance system. Membership of a health insurance fund is now compulsory and citizens pay a tax-deductible premium of 7.5% of their personal income. Direct reference to care of the elderly can be found in article 2, point c of the Act on Social Care of The new Act on Social Care of 1990 does not contain a specific reference to care of the elderly. Children are legally obliged to provide for their elderly or disabled parents and this can be enforced in court if necessary. According to article 908 of the Civil Code, a person can make an agreement with someone to exchange the ownership of property for help and nursing in case of sickness (Dz.U ) The right to receive care can be found in article 17 of the Act on Social Care (Dz.U ) which states that 1. People living alone, who because of age, sickness or other reasons require the help of others, and do not receive it, have the right to help in the form of care services. 2. Care services can be also received by people, who need help, which family cannot provide. Article 14, point 3 of the Act on Family, Nursing and Parental Benefits (Dz.U ) grants people over the age of 75 the automatic right to a nursing benefit regardless of their state of health. People over 75 living in institutions are not entitled to this benefit. Generally speaking, the State policy concerning assistance to the elderly concentrates on financial assistance to those who are the most socially and economically weak which means that the health needs of elderly people on low incomes often go unmet. The local authorities are responsible for organising social assistance. They do this through Social Care Centres. A variety of services are provided by different organisations. Some services, such as washing, bathing and personal hygiene, are performed by health care workers (e.g. community care nurses). Meals are distributed thanks to the Polish Red Cross, the Polish Committee on Social Welfare and NGOs. Some of the meals come from canteens in care homes and schools. Services are also organised and provided through Community Care Centres, which are public institutions. Staff in these centres are responsible for finding people with low incomes in need of assistance. They also organise the provision of care by making contracts with NGOs, private companies and public institutions. Sometimes, the social workers in these centres provide the services themselves but the centres also open their doors to NGOs and self-help groups. The nursing benefit for people over 75, is extremely low and would not in fact even cover the most basis needs of nursing care. A variety of home care services exist including: managing the household, preventing social exclusion, doing small repairs, laundry, transport, day care centres. Day care centres usually offer 4 to 8 hours of care per day to elderly people. In these centres, the elderly can have a hot meal, take part in various activities and receive care from a nurse. Unfortunately, the number of day care centres is steadily decreasing.

6 IV. Finland In Finland, there are an estimated 300,000 informal caregivers. Only 20,000 of these are official informal caregivers. This number refers to informal care giving in general. Finland has separate legislation on informal care (informal care agreement, financial compensation, required services and respite periods for the family caregiver). In order to provide informal care, the carer and the municipality make an agreement on the provision of informal care. The problem is, however, that the municipalities don t necessarily have enough financial resources to support informal care giving and in different municipalities, inhabitants are not treated on an equal basis when it comes to sorting out the allowance for this kind of support. This means that at present only a proportion of family members providing informal care are receiving an informal care allowance. The Social Welfare Act (710/1982) defines social welfare: social services, social assistance, social allowance and related measures intended to promote and maintain the social security and functional ability of the individual, the family and the community. 17 of this Act defines municipalities responsibilities in organising services (home-help services, support for informal care). The Ministry of Social Affairs and Health in Finland is responsible for general planning, guidance and supervision of services aimed at older people. In Finland, there are 444 municipalities, which are independently responsible for providing social and health care services. According to the Act on Planning and Government Grants for Social Welfare and Health Care (733/1992), municipalities receive financial support from the Government in order to organise these services. Each municipality organises services independently, which means, for example, that they are responsible for organising home help, housing services, institutional care and support for informal care. The way that services are organised may vary. During the past decade, increasing attention has been paid to the role of different bodies in organising and funding services. The overall policy still holds that the public sector (municipalities) is responsible for organising services. The role of the private sector (including non-governmental organisation/foundations, in which the municipalities often have their representatives) in providing services has also grown. The role of non-governmental organisations is particularly important in the field of housing services (sheltered homes). In Finland, all inhabitants are legally obliged to have social insurance. This obligatory social insurance is intended to cover everyone for the financial impact resulting from old age, work disability, sickness, unemployment and death of dependents. However, there is inequality in access to services because the level of services depends on which municipality people live in. The role of service providers from the private sector has therefore become more important and expectations for the future are high. However, private services don t exist in all municipalities. The use of service vouchers is an option for people who need home services. Municipalities can offer these vouchers to their inhabitants in order to buy services from the private sector.

7 The Government s Target and Action Plan for Social Affairs and Health for and its recommendations specify the goals relating to social welfare and health care policy. In the plan, the Government sets down for the next four years the development targets and recommendations for social welfare and health care. In this plan, there are guidelines for care and services for elderly people. The main policy aim is to ensure that as many older people as possible are able to live independent lives in their own homes. These targets and recommendations apply primarily to the municipalities. The plan also includes recommendations for measures through which the central government can support the municipalities in reaching their targets. In order to carry out this policy each municipality is expected to have an up-to-date policy strategy concerning care for older people that safeguards their social rights. The strategy should include a service development programme, the starting point of which is to ensure a good quality of life for older people, their self-determination and independence regardless of their functional capacity. There are relatively few municipalities, which have a special strategy concerning dementia care. The Six State Provincial Office creates the conditions for the implementation of social and health care services in the province. It also steers and monitors the delivery of these services. The State Provincial Office networks with service providers and users and various organisations across administrative boundaries. In collaboration with municipalities, it supports the development of social and health care services according to national objectives, as well as the implementation of preventive social and health care policy. The State Provincial Office helps ensure equal access to welfare services for every citizen regardless of where they live. The tasks include for example: 1) steering and monitoring of municipal social and health services and preventive work 2) licences for providers of private social and health services and monitoring the practitioners. Although there is national legislation in place and the Ministry of Social Affairs and Health gives recommendations regarding service provision, actual practices vary widely in the 444 municipalities in Finland because of their independent role. Although there are recommendations to the municipalities on providing care and services, actual practice with regard to testing and evaluation of functional capacity as well as the evaluation of the need for services and so on varies. In Finland, the main service providers are municipalities. Then there are non-governmental organisations (for example The Central Union for the Welfare of the Aged, Finnish Red Cross etc.). In addition to this there are dozens of private service providers, who provide homecare and home services for elderly people. Municipalities are responsible for organising services for their inhabitants. Tax revenues finance service provision/organisation. The costs of the services provided by municipalities for their clients are determined by their income. Financial support is dependent on the municipality s age structure and the size of its population. However economic constraints dictate the level of service provided. There are areas/municipalities, especially in eastern and northern Finland where local authorities are experiencing financial difficulties (because of migration, age structure in the municipality and tax revenue).

8 Municipalities can produce services themselves, or they can buy services from private service providers (which are private firms or Non-Governmental Organisations). Non-Governmental Organisations provide services like sheltered houses and home care. The proportion of costs met by service recipients themselves has increased. In some municipalities, home help services and home nursing have been co-operated for home care units. When organising home care (nursing and services), a written plan is drawn up for each client in which the aims, methods and all providers are defined. In some cases, it includes a plan for rehabilitation as well. Home help services provide assistance when a person, owing to an illness or reduced capacity, needs help at home in order to cope with routine daily activities. Help is provided by home helpers and practical nurses. They monitor the clients state of health and provide guidance and advice. Services are also provided in the evening and at weekends. Municipal health centres employ separate personnel, who have trained as specialised nurses, registered nurses and practical nurses. The home nursing service includes giving care, taking samples and performing tests. Nowadays even more demanding nursing is provided at home, because many people want to live at home until the end of their lives. These services also involve supporting family members. Home-help services cover the performance of or assistance with functions and activities related to housing, personal care and attendance or activities in normal daily life. Support services are intended to help older people to manage socially in everyday life. Services include the provision of meals, daytime activities, transportation and services, bathing, laundry and cleaning services. Municipalities determine the range and cost of each service.

9 V. Spain In Spain, the provision of home care services is in the stage of development with about 20% of communes offering such services. However, this is not sufficient to cover demand and it is estimated that only about 1% of the elderly receive home care services provided by the government. The main aim of social services network is to keep elderly people in their homes for as long as possible. The vast majority of elderly dependent people have to rely on services provided by informal carers. Care of elderly and dependent people tends to be seen as a family obligation. In the Spanish Civil Code (Book 1), it is stated that the spouse and children of elderly dependent people are responsible for their maintenance and care which covers everything that is essential for sustenance, shelter, clothing and medical assistance. The extent of the maintenance to be provided depends on the means of the providers and the needs of the dependent person. The obligation to provide maintenance comes to an end when the provider dies or when their wealth has fallen to such a level that continuing to do so would mean having to neglect their own needs or those of their family. Citizens do not have a legally established right to social services. The provision of such services is at the discretion of the Autonomous Administration. Access rights are governed by legislation at the level of the autonomous communities. The main criterion of the social service network is to keep the elderly in their own environment for as long as possible. The main social services are therefore aimed at maintenance in the home. There is also a residential type network. These services generally concentrate on attending the dependent elderly who live alone. The need is also recognised to help subjects with few resources. Health care services are organised by the autonomous communities. Each community has a Health Service and draws up a Health Plan which outlines which activities are necessary in order to meet the objectives of its own Health Service. Amongst other services provided by the health services of the autonomous communities, there is primary care which includes health care in the home and care specifically for the elderly. Home care services are free for people who are on the minimum pension. People who have an income twice as high as the minimum pension must pay for the services whereas those on an intermediary income must pay a certain amount which is calculated on the basis of their income. Health care is funded exclusively through general taxation and not through social security contributions. Home social services are financed jointly by the Ministry of Social Affairs, the regional ministries of Social Welfare and the municipalities. Home visits by general practitioners and primary care nurses are funded through the Public Health Service. In addition to government provided services, voluntary associations and not-for-profit associations such as the Red Cross also provide social home care services.

10 Home care services include primary care social services, social work, assistance with household tasks, meals-on-wheels and tele-alarm services. However, these services are not available in all the autonomous communities. In practice, home care services are more or less limited to household tasks (which also includes laundry and shopping). This seems to be based on the choice of the elderly people many of whom think that personal care should be carried out by the family.

11 VI. Sweden The Ministry of Health and Social Affairs in Sweden is responsible for general planning, guidance and supervision aimed at older people. The overall policy is that people have the possibility to live independently and safely in their own homes as long as they wish with support and home-care if needed. The targets are established by the Swedish Government and Parliament. The care of older people is regulated by three laws. Each law regulates in a different way what the public sector can expect in relation to the individual and what kind of rights the individual has. The laws are as follows: - the Law of Health and Medical Services (HSL) 1982:763; - the New Social Service Legislation (SOL) SFS 2002:453 (which came into force on 1 January 2002); and - the Law of Support and Service to Certain Persons with Handicap (LSS) 1994 which is a law of rights and carefully specifies the obligations of municipalities and county councils as well as individual rights. Only younger people, under 65 years, with dementia have a right to receive help from a personal assistant instead of home care. The HSL includes an obligation of health service authorities to provide home care services if the needs cannot be met in any other way. Much of the care is carried out by families (informal caregivers). However, there is no statutory obligation for children to care for or financially support their parents. In the Social Service Legislation there are rules which state that the municipalities shall give those who need it, i.e. elderly people and those with disabilities, the kind of support they need which among other things includes home care services. The municipalities are independently responsible for providing social and home care. Social legislation provides a legal framework which gives the municipalities freedom to develop the law according to local conditions and political decisions. They can therefore interpret their obligations differently. Many municipalities have developed their own informal guidelines on service provision with the result that in some areas, for example, elderly people who only need help with cleaning are no longer eligible for home-help. Some have introduced means testing for some services. In Sweden, the welfare of the elderly is divided between three levels of government: - at national level: the Parliament/Government (responsible for establishing policy aims and directives by means of legislation and economic steering measures) - at regional level: the county councils (responsible for the provision of medical and health care) - at local level: the municipalities (responsible for meeting the social services and housing needs of the elderly) In 1992, the Swedish government implemented the Community Care Reform (known as the Ädelreform) which involved the decentralisation of responsibility and resources for the care of the elderly from regional to local governments. Half of the municipalities, 144 of 290, in the country have now taken over responsibility for health and medical care in ordinary living. In the other municipalities, the county councils are responsible.

12 The municipalities are responsible for organising service and home care for their inhabitants. They can provide services themselves or they can buy from private providers. The local authorities are obliged to have insight into and keep control of both their own and private type of care. Support from voluntary organisations is limited. The municipalities are responsible for providing assistive devices for the elderly. The fees charged for home help are determined by the amount of help needed and a person s income. Nevertheless, people receiving home care only pay a fraction of the actual cost. Also, since 1 July 2002, there has been a maximum fee for elderly patients resident in the municipalities. The provision of services is based on an assessment of the person s housing, services and care needs. This is usually carried out by a municipal care manager, or as is often the case for elderly people, by an interdisciplinary care planning team. Entitlement to aid, insofar as this concerns the care of elderly people, includes amongst other things help in the home with services and personal care if the needs cannot be satisfied in other ways. The type of home care provided can be divided into different services which involve practical help with running of the home, cleaning and laundry, help with purchases and other important errands, as well as cooking and help eating. Help with care means personal help with tasks which are needed in order to satisfy the person s physical, mental and social needs. It may be help with eating or drinking, getting dressed and moving, help with personal hygiene, activities to break isolation, measures to ensure that the person feels safe and secure at home, or a safety-alarm (which only people with mild dementia can use). It is possible to get home care and medical care every day of the week, in the evening and at night. In addition to home help, other municipal services for the elderly include transportation services, foot care, meals on wheels, security alarms, housing adaptations and disability support, etc.

13 VII. France Home help is intended to provide assistance with everyday tasks to people aged 60 or more to enable them to carry on living in their own homes. The aim of home nursing care services is to prevent, postpone or shorten stays in hospital or residential care institutions. The Elderly Dependency Act of 20 July 2001 introduced the allocation personalisée d autonomie (individual attendance allowance) known as APA. This allowance, paid to dependent people over the age of 60, is intended to cover the costs of any assistance they need due to the loss of their ability to care for themselves. According to article L113-1 of the Code de l Action Sociale et des Familles, any person over 65 without sufficient resources may benefit either from home help or a place in a private home or establishment. This home help may take the form of a payment or actual assistance with household tasks (art. L of the above-mentioned code). It is stated in article 205 of the French Civil Code that adult children have a legal obligation to provide maintenance to their parents and other ascendants if in need. This obligation extends to daughters-in-law and sons-in-law in certain circumstances with regard to their parents-in-law (article 206). Home help is partly financed by retirement schemes (depending on the income of the person receiving the service) and partly by social welfare benefits provided by the département. Certain services, such as meals-on-wheels and house alarm systems are often financed by regional governments and recipients may have to contribute towards costs. Home nursing care services and other paramedical services, on the other hand, are fully financed by the healthcare system. There is a growing number of freelance nurses. Home care services for elderly people are mainly provided by private non-profit making associations and by municipalities. Many services are provided by volunteers and are therefore cost free. People who need assistance (but to a lesser extent than that needed by people who are entitled to the individual attendance allowance) receive special allowances or increased benefits to pay for services from third parties. The Law of 26 July 2005 on Personal Services and Social Cohesion introduced the cheque emploi service universel (CESU) which came into force on 1 January This replaces the cheque emploi service and the titre emploi service. CESUs can be purchased by individuals and used to pay directly for services required by an individual, including home help for elderly or disabled people, ironing, gardening and general housework. The APA can take the form of services or cash and is paid irrespective of whether the person lives at home or in an institution. The allowance is for human and technical assistance, not the provision of care which would be covered by health insurances. People in receipt of the APA can choose whether to pay for a service or to pay for a private person to provide the service (with the exception of spouses). A private person who is paid to provide a service must declare this as a salary. Home nursing care services provide people with the necessary assistance to carry out essential activities of daily life.

14 VIII. Germany The Social Dependency Insurance Act of 26 May 1994 relating to Care Insurance made it compulsory for people to subscribe to the Long-Term Care Insurance (LTCI). People on a higher income, who are consequently not subject to statutory health insurance, are not obliged to subscribe to the long-term care insurance. However, they must prove that they have a private long-term care insurance policy. Various diseases or disabilities are listed in the care legislation. These include psychiatric illnesses and psychological, physical and mental disabilities such as dementia or other forms of age-related mental decline. In order to be eligible for support or care under the LTCI, a person must have a recognised disease or disability as well as a recognised need for care. The Act was implemented in two stages: first for home care in April 1995 and then for institutional care in July The Complementary Nursing Act was passed in The aim of this Act was to grant a yearly amount to carers or people with dementia in order to purchase additional services. The LTCI is financed through a tax of 1.7% of the gross wage which is shared equally between the employer and the employee. The LTCI is obligatory for every person who has a health insurance and also for people who are privately insured. The employer is compensated through the designation of one day s holiday as a working day. A person s financial situation and the availability of assistance from the family are not taken into account when judging eligibility. Since 1 April 2004, pensioners have been obliged to pay full contributions to the LTCI. Prior to 2004, pension insurance funds paid half of the cost. The LTCI covers personal hygiene, nutrition, mobility and housekeeping. There are four levels (I, II, III and special hardship) and a person must need substantial help for at least 6 months to qualify. Within each category, a specific amount is payable for each kind of assistance needed and this differs according to the person providing the assistance/service. For this reason, the allowance can be paid either to the person with dementia so that they can pay carers in cash or directly for services. The allowance granted under the Complementary Nursing Act of 2002 amounts to a maximum of EUR 460 per year and is especially for people who have a significant need for care and supervision beyond that already covered by care insurance provisions. The care allowance can only be used to pay for day or night-nurses, short-term care, special services of general supervision and care from recognized care providers, and for services from low-level care providers. Non medical home care services are often provided by home health assistants and housekeepers who provide assistance with household chores. Certain services such as shopping and simple household help may also be provided by young men who decide to do community service instead of military service.

15 IX. United Kingdom 1) England In November 1989, the Government published the White Paper Caring for People, which laid out a framework for community care changes. Community care was defined in the White Paper as providing the right level of intervention and support to enable people to achieve maximum independence and control over their own lives. The National Health Service and Community Care Act 1990, which came into force in 1993, made the necessary legal changes to implement the objectives set out in Caring for People. This act, as modified by the Health and Social Care Act of 2001, provides the framework for assessment of social care needs. If, whilst being assessed, it becomes clear that a person is disabled, the local authority is obliged under the Community Care Act to assess that person under the Disabled Person s Act Under the latter act, a person may be entitled to practical assistance in the home amongst other services. Healthcare is free at the point of delivery and funded by taxes not insurance. However, most social care is provided by local authorities who demand a modest means-tested contribution from patients. Although charges for home care services are at the discretion of local authorities, they are subject to the Fairer Charging Guidance issued to the Social Services Departments (SSD) under section 7 of the Local Authority Social Services Act The NHS and Community Care Act 1990 gave local governments the opportunity to concentrate their efforts on community needs rather than on medicalised homes. Responsibility for care fees was transferred from the Department of Social Security to local authorities. They could decide which part of their budget should be allocated to community services and which part should be dedicated to residential care. The aim of the act is to enable people to stay in their homes for as long as possible. It gives local authorities the responsibility to assess people s needs. Local authorities differ in the kind of services they offer and the way that they are delivered. There is no obligation to actually provide services, just an obligation to assess needs. The Community Care Act has resulted in a growing number of different services designed to support people in their own homes. However, the range and level of services vary a great deal from area to area. Financial constraints sometimes mean that it is not possible for someone to be supported at home. Local authorities are not legally obliged to provide community care for individuals if this would cost more than moving them to a residential or nursing home, although they sometimes will. On 27 March 2001, the UK government published the National Service Framework (NSF) for Older People. This document, which applies just to England, sets national standards for the care of older people who are being cared for at home, in a residential setting or in a hospital. 2) Scotland Community care is a major priority of the Scottish Parliament. It aims to provide support and services for people with physical and/or mental health problems who are living at home or in a care home.

16 The relevant legislation in Scotland governing the provision of home care services is The Community Care and Health (Scotland) Act This Act extended the range of duties placed on local authorities and assigned new powers to local authorities and NHS Scotland. In the past, local authorities or councils had main responsibility for assessing local need and for providing and co-ordinating services through their social work departments. However, services can now be provided by a variety of organisations e.g. housing associations, health authorities, voluntary sector agencies such as Alzheimer Scotland and private service providers. On 1 July 2002, people over 65 years of age were granted free personal as well as nursing care. This was implemented under the Community Care and Health (Scotland) Act This is not dependent on financial status, capital assets, marital status or the amount of care provided by an unpaid carer. Personal care covers both personal care and personal support (as defined in the Regulation of Care (Scotland) Act